Extremely late recurrence of adult granulosa cell tumor in the retroperitoneal space 27 years after surgery manifesting as a liver tumor.

We present a patient with an extremely late and rare manifestation of recurrent AGCTs. After 27 years, the recurrence of the disease is unlikely, and the manifestation of liver lymphatic cavernoma is not a premise for suspicion of AGCT recurrence. The retroperitoneal site of recurrence is also very rare, and surgical resection of the tumor may not always be possible. We suggest that the decision to resect should always be made if possible. Patients with a history of AGCT should always be carefully considered for surgery for other indications, as even extremely long recurrences are possible.

Kidney Transplant Loss Due to May-Thurner Syndrome: Case Report and Review of the Literature.

BACKGROUND: May-Thurner syndrome (MTS) is an extrinsic venous compression by the arterial system against bony structures in the iliocaval territory. The most common variant of MTS is due to compression of the left iliac vein between the overlying right common iliac artery and the fifth lumbar vertebrae. The prevalence of MTS is unknown; therefore, there are only a few publications about MTS in kidney transplant recipients. Risk factors that may progress from usually asymptomatic to symptomatic MTS are female sex, scoliosis, dehydration, coagulation disorders, and radiation. Clinical presentations include acute extremity pain and swelling, venous claudication, and chronic signs of venous insufficiency. METHODS: We describe a 63-year-old man who underwent kidney transplantation (left iliac fossa). Four days after transplantation, a graftectomy was done due to graft rupture caused by renal vein thrombosis. After imaging studies, a diagnosis of MTS was established. The patient had no typical symptoms of MTS. However, an incidence of right lower limb thrombosis was observed, and due to vertebral discopathy, the patient underwent surgery with implantation of a vertebral implant. RESULT: After a successful second transplantation on the right side, incidents of thrombosis were observed: superficial thrombosis of the upper limbs and massive deep vein thrombosis of the right lower limb. Thrombophilia was recognized, the graft function is stable, and anticoagulation therapy is being continued. CONCLUSION: Asymptomatic MTS in the case of coincidence of other risk factors, such as coagulation disorders, history of vertebral operation, and additional pressure of the graft, can result in graft failure.

Changes in the Serum Fatty Acid Profile After Anhepatic Phase of Orthotopic Liver Transplantation Procedure.

During orthotopic liver transplantation (OLT), the patients' body remains deprived of this organ for some time, which could cause critical changes in the levels of various metabolites in the circulation, including fatty acids. Thus, the aim of this study was to determine whether the liver transplantation procedure leads to significant changes in the FA profile in serum lipids after the anhepatic phase. Our gas chromatography-mass spectrometry analysis revealed that after transplantation, serum levels of myristic and palmitic acids significantly decreased, whereas serum levels of very long-chain FAs containing 20 or more carbons in their chains were increased. These results indicate that the anhepatic phase during liver transplantation produces significant changes in serum fatty acid levels, and emphasizes the role of the liver in the metabolism of very long-chain fatty acids.

The Role of Fatty Acids in Non-Alcoholic Fatty Liver Disease Progression: An Update.

Non-alcoholic fatty liver disease (NAFLD) is a major public health problem worldwide. NAFLD (both simple steatosis and steatohepatitis) is characterized by alterations in hepatic lipid metabolism, which may lead to the development of severe liver complications including cirrhosis and hepatocellular carcinoma. Thus, an exhaustive examination of lipid disorders in the liver of NAFLD patients is much needed. Mass spectrometry-based lipidomics platforms allow for in-depth analysis of lipid alterations in a number of human diseases, including NAFLD. This review summarizes the current research on lipid alterations associated with NAFLD and related complications, with special emphasis on the changes in long-chain and short-chain fatty acids levels in both serum and liver tissue, as well as in the hepatic expression of genes encoding the enzymes catalyzing lipid interconversions.

Clinical presentation and outcomes of cholecystectomy for acute cholecystitis in patients with diabetes - A matched pair analysis. A pilot study.

PURPOSE: The primary aim of this study is to compare the clinical course and laboratory parameters of acute cholecystitis in patients with diabetes vs. patients without diabetes. MATERIALS AND METHODS: The study involved patients who underwent emergency cholecystectomy in the Department of General, Endocrine and Transplant Surgery of University Clinical Center in Gdansk (Poland) between 2007 and 2017. There were 267 patients included in the study. The control group of 197 patients was age and sex matched at a 3:1 ratio. The following was compared between the groups: symptoms at admission, course of surgery, postoperative course, length of hospitalization, total costs of hospitalization and antibiotic therapy, other than routine perioperative prophylaxis. RESULTS: There was no significant difference between the patients with and without diabetes regarding symptoms at admission. Operative and postoperative complication rates were significantly higher in the patients with diabetes. The operative time and length of hospitalization were significantly longer in the study group. The conversion rate was not higher in the study group, but classic surgery was performed significantly more often. The patients without diabetes had less pronounced symptoms with more locally advanced disease. CONCLUSIONS: Our study demonstrates that patients with diabetes have a significantly more eventful course of acute cholecystitis than patients without diabetes. Patients with diabetes should therefore be qualified for cholecystectomy early in the course of acute cholecystitis.

Patients seeking information about colonoscopy - lessons learned from Google.

INTRODUCTION: Every year in the USA over 14 million colonoscopies are performed. It requires high-quality examinations as well as a relevant information strategy. Colonoscopy compliance is not satisfactory, which to some extent might be related to patients' attitudes towards colonoscopy, which are based on information and emotions. AIM: In the current study we addressed the questions of what kind of information people seek and get when they search the Internet for "colonoscopy". MATERIAL AND METHODS: Using the Google Trends web facility we analysed search results of "colonoscopy", related searches, and annual and weekly search trends. Fields of interest analysis was performed based on the related searches. RESULTS: Patients are generally offered quality data on the first result page of a Google search biased only by Wikipedia scoring first on the result list. The number of "colonoscopy" searches is stable over the week with a significant decrease on weekends, and stable over the year with significant decrease around Thanksgiving day and in the Christmas/New Year's Eve Period. The most common field of search is colonoscopy preparation, thus underlining the importance of this part of colonoscopy. CONCLUSIONS: Internet search provides abundant information on colonoscopy. In general, this information is accessible, preferred by patients, and of good quality. This should be kept in mind by healthcare providers while educating patients about colonoscopy.

Partial pancreatic resection along the embryological fusion plane - no longer a fantasy.

BACKGROUND: The embryological connection between the dorsal and ventral pancreatic regions divides the pancreas into two segments. This anatomical dependence allows segmental pancreatic resection through the embryological fusion plane (EFP). The advantages of limited pancreatic resection are the preservation of the natural continuity and function of the gastrointestinal tract and the avoidance of the metabolic and endocrine consequences of total resection of the pancreas and the duodenum. MATERIALS AND METHODS: Two patients are described who underwent anatomicalsegmentectomyof the pancreatic head along the EFP for the treatment of pancreatic cystic tumor and main duct IPMN. The authors suggested diagnostic and intraoperative management leading to qualification for pancreatic resection along the EFP. RESULTS: Pancreas and duodenum sparing surgery is an opportunity for patients in terms of the post-operative quality of life. Indications for this kind of surgery are limited and case selection is very difficult. The procedure for embryological bud resection is highly complicated includes a high rate of possible complications. On the other hand high volume centers may offer this procedure at an acceptable rate of complications in selected cases. CONCLUSIONS: Accurate diagnosis with a vascular anatomy and biliary and pancreatic duct configuration give grounds to analyze pancreas-sparing surgery. The operation plan requires careful 3D planning and an experienced team. Bipolar electrocautery, micro surgical tools and intraoperative cholangiography and pancreatography are helpful.

Cancer stem cells as targets for DC-based immunotherapy of colorectal cancer.

The therapy of colorectal cancer (CRC) patients is often unsuccessful because of the presence of cancer stem cells (CSCs) resistant to conventional approaches. Dendritic cells (DC)-based protocols are believed to effectively supplement CRC therapy. Our study was aimed to assess how the number and properties of CSCs isolated from tumor tissue of CRC patients will affect the biological characteristics of in vitro modified DCs. Similar procedures were conducted with the using of CRC HCT116 and HT29 cell lines. We found that the detailed configuration of CSC-like markers significantly influenced the maturation and activation of DCs after stimulation with cancer cells lysates or culture supernatants. This basic stimulatory effect was enhanced by LPS that is normally present in CRC CSCs niche. The increased number of CD29+ and CD44+ CSCs presented the opposite impact on treated DCs as showed by many significant correlations. The CD133+ CSCs seemed to impair the functions of DCs. The more CD133+ CSCs in tumor sample the lower number of activated DCs evidenced after stimulation. Moreover, our results showed superiority of the spherical culture model over the adherent one since spherical HCT116 and HT29 cells presented similar influence on DCs properties as CRC patients cancer cells. We concluded that the DCs features may depend directly on the properties of CSCs affected by progression status of tumor.

Diagnosis and treatment of obscure small bowel bleedings - analysis of double balloon enteroscopy role in diagnosing and treatment algorythm on basis of own material.

Introduction Obscure gastrointestinal bleeding (OGIB) is defined as a reccurent bleeding to gastrointestinal tract without evaluated origin, despite detiled endoscopic and image diagnostics. Mots common reason of OGIB i small bowel bleeding (SBB). Methodology Retrospective analysis of patients hospitalised in Gastroenterology Department of 7 Szpital Marynarki Wojennej w Gdansku with suspicion of OIGB. Results Double balloon enteroscopy was performed in 31 cases. Origin of bleeding was founded in small bowel in 87% of cases and in 64 % successfull,simultaneous therapeutic procedure was performed. No clinically relevant complications were noticed. Conclusion According to actual diagnostic algorythms of OGIB, double balloon enteroscopy is highly effective also in polish medical care system. This tehnique is a safe and effective tool in diagnostics and treatment of SBB, but its availability is still limited in Poland. Abstrakt.

Structured box training improves stability of retraction while multitasking in colorectal surgery simulation.

BACKGROUND: Laparoscopic colorectal surgery has an established role. The ability to multitask (use a retraction tool with one hand and navigate a laparoscopic camera with the other) is desired for efficient laparoscopic surgery. Surgical trainees must learn this skill to perform advanced laparoscopic tasks. The aim was to determine whether a box-training protocol improves the stability of retraction while multitasking in colorectal surgery simulation. MATERIALS AND METHODS: Fifty-eight medical students were recruited to attend a basic laparoscopic box-training course. Ability to perform steady retraction with and without multitasking was measured initially and at the conclusion of the course. RESULTS: Before training, students demonstrated a decrease in performance while multitasking with a greater maximal exerted force, a greater range of force, and a greater standard deviation for traction and minimal exerted force, range of force and a greater standard deviation for countertraction. Statistically significant improvement (lower maximal exerted force and lower range of force) was observed for traction while multitasking after training. After the training, no statistically significant differences were found when the student performed a single task versus multitasking, both for traction and countertraction. CONCLUSIONS: A structured box-training curriculum improved the stability of retraction while multitasking in this colorectal surgery simulation. Although it did not improve stability of retraction as a single task, it did improve stability of retraction while multitasking. After training, this enables the trainee to retract as efficiently while operating the camera as they retract when only focusing on retraction as a single task.

Cost-effectiveness of benign Wirsung duct strictures treatment in chronic pancreatitis.

INTRODUCTION: Chronic pancreatitis (CP) is an important problem for modern medicine, the healthcare system (Poland - NFZ) and the national insurance system (Poland - ZUS). The chronic nature of the disease, the lack of targeted treatment and the low mortality rate lead to an accumulation of patients who demand expensive treatment, both conservative and invasive. Rising costs in health care are forcing the need for a more cost-effective method of treatment. AIM: The primary aim of this study was to perform a retrospective calculation of costs in both surgical and endoscopic treatment, hospital stay, healthcare, and public insurance of patients suffering from chronic pancreatitis. Parallel quality of life analysis was performed. It was possible to develop a cost-effective therapeutic algorithm for patients with an uncomplicated stricture of Wirsung's duct within the Polish health care system. RESULTS: In Poland, the hospital costs of endoscopic treatment of patients with chronic pancreatitis were higher than those of the surgical treatment group despite both resulting in a similar life quality. CONCLUSIONS: From a cost-effectiveness perspective, it was shown that surgical intervention is a more cost-effective therapy than endotherapy. Furthermore, patients with benign stricture of the main pancreatic duct in chronic pancreatitis should not be treated with endotherapy for longer than 12 months.

FasR and FasL in colorectal cancer.

Colorectal cancer (CRC) is one of the most common solid organ cancers prevalent worldwide causing, in spite of advancing therapeutic methodology, high rate of patient mortality, especially due to metastasis development. The cancer stem cell (CSC) theory of tumor growth indicates that CSCs within the tumor mass have great capacity to initiate and sustain tumor growth. Following the suggestion that Fas signaling can be engaged in apoptosis, tumor maintenance, senescence or DICE (death induced by CD95 or CD95L elimination), the attempts to broaden the knowledge concerning the relationships between CSCs features and FasR/FasL appeared to be necessary. The most important advantage of our study was the simultaneously analysis of CSCs from commonly used CRC lines (HCT116 and HT29) and tumor fragments collected from CRC patients. Moreover, the sphere-promoting expansion of CRC lines brought a specific three-dimensional specific environment for CSC exploration. We further investigated the function of Fas signaling in CRC lines depending on the culture mode as we incubated HCT116 and HT29 cells with anti-FasR agonistic antibodies. It appeared to act in a line-dependent and culture mode-dependent manner and influenced some particular features of CSCs such as spherogenicity, proliferation and phenotype. Additionally, the analysis of mRNA level showed that disease progression is associated with significantly increased expression of FasR and/or FasL. In conclusion, our observation seems to confirm that spherical model of cancer lines is more reliable for some sophisticated analysis because of their greater resemblance to the CSCs from human CRC samples in comparison to commonly used adherent cells, at least according to aspects of their biology analyzed in this study. That can be extended to the resemblance of in vitro sphere forming conditions to the in vivo environment. However, the greatest difference concerns the level of apoptosis, thus, this issue require further experiments.

Dynamics of quality of life improvement after floppy Nissen fundoplication for gastroesophageal reflux disease.

INTRODUCTION: Gastroesophageal reflux disease (GERD) has a negative impact on global quality of life (QOL) of patients. In patients affected by GERD, laparoscopic Nissen fundoplication is one of the most commonly performed laparoscopic procedures worldwide. AIM: To prospectively analyze the dynamics of QOL as well as severity of pain in patients with GERD, before and after laparoscopic floppy Nissen fundoplication. MATERIAL AND METHODS: The study involved 104 consecutive patients operated on for GERD in whom laparoscopic floppy Nissen fundoplication was performed. QOL was assessed before surgery and 1, 3, 6, 12 and 24 months after. The following instruments were used: FACIT-G, FACIT-TS-G, GIQLI, GERD symptom scale. RESULTS: It was found that symptom relief and quality of life improvement presented different dynamics in the postoperative course. Observations revealed relief of symptoms 1 month after surgery and improvement in QOL related to the gastrointestinal tract and pain 3 months after surgery. Global QOL increased significantly as late as 12 months after surgery. CONCLUSIONS: Gastroesophageal reflux disease is a chronic disease of long duration, leading to impairment of quality of life. Patients, apart from typical symptoms of GERD, suffer from pain of significant severity. QOL improves significantly after surgery. Surgical treatment results in relief of GERD symptoms, which leads to gradual improvement of QOL.

From four-parathyroid gland exploration to a minimally invasive technique. Minimally invasive parathyroidectomy as a current approach in surgery for primary hyperparathyroidism.

Complete surgical resection of hyperfunctioning parathyriod tissue is essential for the treatment of primary hyperparathyroidism. During recent years, minimally invasive surgery has been successfully applied in neck exploration, because of significant developments of guidance by intraoperative scans, the use of quick, intraoperative PTH assay, and also preoperative imaging procedures such as high resolution ultrasonography and sestamibi scintigraphy. The results of operations which are performed with minimally invasive techniques are comparable to those of conventional surgery, and provide advantages with regard to cosmetic result, length of hospitalisation, and reduced post-operative pain.

New comprehensive surgical curriculum of pre-graduate surgical education.

INTRODUCTION: Surgical education has become one of the most important directions in modern surgery evolution. To meet growing need for appropriate training in laparoscopic and, even more importantly, classic surgical skills, a curriculum involving contemporary tuition methods is needed. Advanced, structuralised training, which includes advanced technologies like virtual reality training, video coaching and motivative aspects of competition, seems to be important for an adequate education programme. MATERIAL AND METHODS: In academic years 2009/2010 and 2010/2011 the Department of General, Endocrine and Transplant Surgery of the Medical University of Gdansk together with the Pomeranian Foundation for Progress in Surgery organized 4480 h of training in that area of classic (2744) and laparoscopic (1736) skills. Both groups were involved in the programme of training in which the two most important aspects were reliable evaluation of the results and effective motivation to work. Skill evaluation at different stages of the programme were based on completion time and quality measurements. Apart from that, at the end of the course, the participants completed a questionnaire on their subjective perspective on this innovative curriculum, the quality and stability of the skills they obtained. RESULTS: In both arms of the programme (laparoscopic and classic) a statistically significant improvement was obtained as early as after the second and third sessions in half of the exercises. The acquired skills were stable over time, as proved by the plateau of completion time achieved in 11 out of 12 exercises. The results of the post-training questionnaire revealed that the participants were very satisfied with the structuralised form of training and appreciated the motivational role of competition. CONCLUSIONS: Contemporary surgical training should be organized as a systematic, well-evaluated and goal-oriented programme similar to the one proposed by our team. The use of contemporary training aids should be utilized in training of every surgical skill, not only laparoscopy. This form of training, associated with the component of competition, enables good and stable results to be achieved, as well as high satisfaction of trainees.